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help with diagnosis for fracture

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by namita namita (New Member) New Member

namita works as a Lpn.

754 Visitors; 10 Posts


Hello everyone,

as usual i need help with my care plan. I always have problem in writing or wording r/t factors in nursing diagnoses because English is not my first language.

My patient is 81 yr old female with a right hip(femur) fracture with bruises on right hip. she also has swelling, ecchymosis, and pain in right wrist. although hipfracture has been diagnosed in X-ray but she was suppose to go for x-ray of wrist that afternoon and i don't know the results. she seemed to be confused and wanted to get out of bed and walk and then I had to remind her of her condition and risk for fall. she was drowsy and after responding used to go back to sleep. she had foley catheter due to urge incontinence . she also has a medication Detrol for urge incontinence.

Quest. If it was not in her medical history so can I assume it was due to trauma?:uhoh3:

while I was helping her feeding she said " as helpless as a baby". has SCD and ted hose in her left leg. she had 5 lbs buck's traction in right leg. she only felt pain during movement like when turning her to to place a pillow under hip. rated pain as 4/10 intermittent in right hip.

Nursing diagnoses: 3 physiological

Acute Pain r/t :uhoh3:muscle spasm and soft tissue trauma secondary to fractured right femur aeb reported pain 4/10, facial grimacing and guarding behavior.

what culd be 3 goals for the above diagnosis?

can it be -1- patient will verbalise pain less than 3 on VAS scale after intervention

2-patient will verbalise and demonstrate at least two non pharmacological methods of pain management by the day of discharge.

3- :uhoh3:don't know but want to include interventions regarding body positioning and turning maintaing immobilization HELP Needed

Impaired physical immobility r/t femur instability and pain, AEB inability to lift right leg, pain on ROM, buck's traction

(Is it Correct:uhoh3:)

Bathing and hygiene, dressing and grooming Self care deficit r/t :uhoh3:swelling, pain and edema in right wrist and immobilization and aeb inability to use right hand and asking for help:uhoh3:

urinary incontinenece r/t age and reaction to trauma aeb foley catheter

2 psycosocial

situational low self esteem/ powerlessness:uhoh3: r/t loss of independent functioning aeb patient feeling " as helpless as a baby"

Knowledge deficit regarding activity restriction r/t lack of recall or cognitive impairment ( how to relate it to confusion:uhoh3:) aeb patient wanting to get out of bed and walk

anxiety r/t process of hospitalization, unfamiliar sorrounding, and scheduled surgery aeb restlessness and facial tension

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